210102881-4-27-2023-21-AS-CFES-CRAUZR-20230427160159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:02:13 PM

Document Has Been Signed on 04/27/2023 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SCHON HYME REST HOME		FACILITY NUMBER:	210102881
ADMINISTRATOR:	ALBERTINA CAMACIANG		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(415) 524-8058
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS:	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Staff Member, Nancy		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Nancy Mckee. Administrator, Tina Camaclang was available via telephone. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 3 ambulatory and 9 non-ambulatory residents for a total capacity of 12 residents. Facility has an approved hospice waiver for 3 individuals. Facility is currently on a Non-Compliance Plan. Administrator, Tina Camaclang, arrived later during visit at approximately 11:30AM. LPA conducted a walk through of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for resident use. Mattress pads were in place or available for resident use. Medication was centrally stored and secure. LPA reviewed 5 of 8 resident records. During review of resident records, it was revealed that the facility recently had a fourth resident admitted on hospice. Per facility's license, facility is approved for 3 hospice individuals at a time. Per conversation with Administrator, it was expected that Resident 1 (R1) would no longer require hospice services by April 2023. At this time, R1 is still on hospice. Resident 2 (R2) was admitted to Hospice in March 2023. LPA discussed with Administrator the documentation required to request for a Hospice Waiver Exception to allow the facility to have 4 individuals on hospice (See LIC-809D) LPA reviewed a sample of staff records. LPA reviewed 4 staff files. Staff files were found to be organized with proper documentation. Administrator's Certificate (6010282740) was current with an expiration date of 02/16/2024. Continued on LIC809C.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 04/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809

LPA and Administrator discussed facility's emergency and evacuation plan. The facility's last fire and evacuation drill was conducted January 2023. Facility's fire extinguishers were last inspected December 2022. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods was within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPA conducted staff and resident interviews.

LPA requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Control of Property
Emergency Disaster Plan (LIC 610D)
Health Screening Report for Administrator (LIC 503)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, 5/26/2023.

Facility to submit the following documents for R2's Hospice Waiver Exception by due date of Friday, 04/28/2023:

A written request for a hospice exception
LIC 602 (Physician's Report)
LIC 625 (Appraisal/Needs and Services Plan - updated to indicate hospice care and needs)
Hospice Care Plan
Staff Training: Hospice Care

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 04/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809C

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC 811 (Confidential Names), LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 04/27/2023 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87632(a)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based records reviewed, the Licensee did not comply with the section cited above. Licensee currently has four hospice residents but are only approved for three. This poses an immediate risk to the health and safety of residents in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a request for a hospice waiver exception to Community Care Licensing for R2 by POC due date of 4/28/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4